New Patient Questionnaire
Dr. Moore’s New Patient Questionnaire
Name: Age: Date:
What problem would like evaluated today (e.g. left knee pain)? ______
______
On the body diagrams use the appropriate symbols to mark where you feel the following sensations:
Numbness Pins and Needles Burning Stabbing Aching
=== ooo xxx /// •••
On the line below please indicate (with an X) how severe your pain is now.
No Pain------Worst possible pain
0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 – 10
When did the problem start (approximately what date)?
Did the problem result from trauma (e.g. an accident)? yes no
If yes, please describe: ______
Have you been evaluated by a physician or received any treatment for this problem?
yes no
If yes, what treatments (check all applicable boxes)?
Pain medicine Brace Physical Therapy
Surgery Injections Alternative Medicine Other______
If you have pain, what is it like (check all applicable boxes)?
Sharp Dull Ache Episodic Constant
Numb Burning Radiating Stiffness Swelling
Joint feels unstable Other______
What makes your symptoms worsen?
Motion Activity Bending Lifting Early morning
Running Touch Standing Lying End of day
Sports Random Overhead activities Other ______
What makes your symptoms improve?
Physical Therapy Ice Heat Medicine
Alternative Meds Injections Sitting Lying down
Exercise Massage Nothing Other______
What is your height (in feet and inches)? ______
What is your weight (in pounds)? ______
Past Medical History: Please check (X) the box next to any problems that apply to you (or the patient if completing for a child).
Heart disease Lung disease Kidney disease
Eye disease Auto-immune disease High blood pressure
Liver Disease/Hepatitis Diabetes Thyroid Disease
Other endocrine disease Ulcers/Reflux Neurological disease
Stroke Epilepsy Skin lesions or rash
Bleeding/Easy bruising Sickle cell disease Other anemia
Cancer Arthritis Gout or pseudogout
Depression Other psychiatric disease
None Other______
Past Surgical History: Please list all surgeries you have had, their dates, and the hospital where the procedure was done.
None
Type of Surgery / Date of Surgery / Name of HospitalHave you had any of the following diagnostic studies performed?
X-rays / radiographs
CT (computed tomography)
MRI (magnetic resonance imaging)
EMG/NCV (electromyogram / nerve conduction velocity)
Bone scan / nuclear medicine study
Who is your primary care doctor or provider?______
Medications:
What medications do you take? ______
______
______
______
Allergies: Please check (X) the box next to any allergies that apply to you.
No Known Allergies Penicillin Sulfa
Iodine Shellfish Cephalosporins
Other antibiotics, medications, foods, or dyes:______
Do you have any difficulty taking anti-inflammatory medicines (e.g. Motrin)?
Yes No Unknown
Review of Symptoms: Please check (X) the box next to any problems that apply to you (or the patient if completing for a child).
Fever or Chills Difficulty sleeping unintended weight loss
Heat or Cold Intolerance Change in Gait Weakness
Loss of control of bowel Loss of control of bladder Numb arm or leg
Dizzy or light-headed Chest Pain Shortness of breath
Night pain Endocrine/hormonal Psychiatric/emotional
Other difficulties:______
Family History:
Cancer Diabetes Heart Disease Stroke
Bleeding Problems Sickle cell anemia Sudden death Arthritis
Other
Social History:
Tobacco use: no yes if yes, packs per day_____, years of use _____
Alcohol use: no yes if yes, amount per week______.
Work status: employed unemployed disabled retired
What is your occupation?______
Marital status: single married divorced separated widow/widower
Handedness: right left ambidextrous
Developmental History: (complete if patient is an infant or child)
Did pregnancy go to full term? yes no unknown
Normal birth / normal first exam? yes no unknown
Normal motor developmental milestones? yes no unknown
Normal verbal developmental milestones? yes no unknown
Are immunizations up to date? yes no unknown
Is the child generally healthy? yes no unknown
If you answered “no” to any of the above questions, please elaborate below:
______
______
Doctor’s Notes:
Patient:
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